Carme Loras

Background: Colonoscopy with stepwise colonic biopsies is the only method for confirming microscopic colitis in patients with chronic watery diarrhoea. Several clinical scores (Cotter, Kane and Atieh) have been proposed to guide biopsy decisions; however, their diagnostic accuracy remains limited. Aims: To develop a derivation‐stage clinical and biomarker‐based score incorporating faecal calprotectin to predict microscopic colitis in patients with chronic watery diarrhoea and to assess its diagnostic accuracy compared with previously reported scores. Methods: A prospective observational study was conducted at two centres, including adults with chronic watery diarrhoea. Clinical data, faecal calprotectin and colonoscopy with biopsies were recorded. Multivariate logistic regression was used to identify independent predictors of microscopic colitis. Score weights were derived from regression β coefficients. Diagnostic performance was assessed using ROC curve analysis, calibration metrics and bootstrap internal validation with 1000 resamples. Results: Among 111 patients, 41 were diagnosed with microscopic colitis. The final score, calculated in 101 patients with available faecal calprotectin, included stool frequency > 5/day, diarrhoea duration ≤ 8 months, body mass index ≤ 26 kg/m ² , and faecal calprotectin > 81 μg/g. It showed excellent discrimination with an AUC of 0.90 (optimism‐corrected AUC 0.88), and no false‐negative cases were observed at the sensitivity‐driven cut‐off. Previously published scores showed lower discrimination in this cohort, with AUCs ranging from 0.63 to 0.72. Conclusion: A score integrating simple clinical variables and faecal calprotectin showed promising diagnostic accuracy for microscopic colitis in this derivation cohort and may support future risk‐stratification strategies in patients with chronic watery diarrhoea.

Occult hepatitis B infection (OBI) is defined by detectable hepatitis B virus (HBV) DNA in liver tissue in the absence of hepatitis B surface antigen (HBsAg) and remains insufficiently characterized in low-endemic European settings. This study aimed to determine the prevalence of OBI using direct HBV DNA detection in liver tissue in a real-world cohort of patients undergoing diagnostic liver biopsy. This observational study included consecutive HBsAg-negative patients who underwent liver biopsy between 2020 and 2023. HBV DNA in liver tissue was quantified by real-time PCR, and clinical and serological data were collected. A total of 86 patients were included. OBI was identified in 4 patients (4.7%). All OBI cases were anti-HBc-positive, and two were also anti-HBs-positive. No cases of seronegative OBI were detected. OBI was observed across different underlying liver disease etiologies, including viral, metabolic, autoimmune, and cholestatic conditions. In conclusion, OBI was infrequent in this cohort and consistently associated with anti-HBc seropositivity. These findings suggest that anti-HBc may help identify individuals with prior HBV exposure in whom occult infection can be detected in liver tissue in low-prevalence settings.

Background: Perianal fistulizing disease (PFD) is a complication that affects about 20% of Crohn’s disease (CD) patients whose etiology remains unknown. Objectives: To identify predisposing events driving fistula formation. Design: Rectal biopsies from CD patients with or without PFD (CD+PFD and CD, respectively; n=31) were collected and subjected to single-cell RNA sequencing (scRNA-seq). Functional analyses were conducted using peripheral CD3+ T cells, intestinal tissue explants, primary fibroblasts and 2D-epithelial monolayer cell cultures. Results: The rectal mucosa of CD+PFD patients is imprinted with cellular and transcriptomic alterations specific to PFD and independent of luminal inflammation, potentially driven by TL1A activation in CD4+ T cells. We identified lymphotoxin beta ( LTB or its functional heterotrimer LTα ₁ β ₂ ) as a novel mediator downstream of TL1A that, along with IL-22, induces a PFD-associated signature in rectal fibroblast and epithelial cells, respectively. This signature includes an increased abundance of fibroblasts, an induction of matrix-degrading enzymes, transcriptomic rewiring of the lamina propria S1 fibroblasts, and an anti-bacterial and immune responses in epithelial cells. Notably, the induction of LTα ₁ β ₂ and IL-22 occurs independently of TNF signaling, revealing a new TL1A-LTα ₁ β ₂ /IL-22 axis that remains active under anti-TNF therapy. Conclusion: Our findings revealed unique cellular alterations in the rectum of CD patients with PFD, highlighting the previously unrecognized involvement of TL1A in mediating this signature and supporting the need for exploring the role of TL1A inhibition as a therapeutic approach for PFD.

Esophagogastroduodenoscopy (EGD) is an effective technique for diagnosing gastric cancer (GC). However, it is estimated that 10% of GCs are unnoticed, constituting missed gastric cancer (MGC). To analyse the incidence of MGC in our area, the characteristics of GC and factors related to MGC were evaluated. This was a retrospective study of patients diagnosed with GC at a single centre between October 2003 and December 2018. MGC was defined as GC undetected in a EGD performed 3 to 36 months before diagnosis. A total of 333 patients with GC were identified, 6% of whom had MGC. MGC was more frequently located at anastomotic site of a previous surgery (p = 0.001), and fewer patients with MGC experienced alarm symptoms (p = 0.001). Using fewer biopsies (p = 0.001) and performing the procedure without sedation were associated to MGC. According to multivariate analysis, the factors associated with MGC were the absence of sedation [OR 3.2 (95% CI 1-10.4)] and localization in the anastomosis of previous surgery [OR 11.5 (95% CI 1.8–72.8)]. Moreover, there were no differences in 5-year survival between patients with MGC and patients without MGC. The MGC percentage was 6%. When an EGD is indicated, regardless of the symptoms, IV sedation is recommended to reduce the risk of MGC. In addition, biopsies of the anastomosis from previous surgery should be considered even in the absence of clear suspicious lesions.

Background and Objectives: Endoscopic retrograde cholangiopancreatography (ERCP) is the primary intervention for malignant distal biliary obstruction (MDBO). However, ERCP may fail for various reasons, requiring alternative interventions such as EUS-guided biliary drainage. Among EUS-guided biliary drainage (EUS-BD) methods, EUS-guided gallbladder drainage (EUS-GBD) is emerging as a viable option for patients who have failed ERCP and EUS-BD. The aim of this study is to evaluate the efficacy and safety of EUS-GBD as salvage therapy for MDBO and its potential role in allowing the initiation of chemotherapy. Methods: This is a retrospective multicenter study of consecutive patients with MDBO with failed ERCP and/or EUS-BD that subsequently underwent EUS-GBD with lumen-apposing metal stent. Results: Ninety-six patients from 9 centers in Spain were included. Technical success was achieved in 99% of patients, while clinical success, defined as bilirubin reduction <50% within 14 days after the procedure, was achieved in 78.1% of patients. Bilirubin levels were normalized in 65.6% of patients. The median time to normalization of bilirubin levels was 15 (7–27) days. Related to continuation of oncological treatment, 44/77 (57.1%) eligible patients were able to start chemotherapy after the procedure, and 12/17 (70.6%) eligible patients underwent surgery in the end. Adverse events were observed in 26.3% of cases, with 3 patients requiring surgery and 3 deaths related to EUS-GBD. Conclusions: EUS-GBD represents a potential alternative to MDBO in cases where ERCP has failed, with an appropriate profile of patients starting chemotherapy. However, in light of the considerable number of adverse events and the moderate efficacy, it may be advisable to consider this approach as a second-line option.

The upper oesophagogastrointestinal (UEGI) tract histology, intestinal morphometry and lymphocyte subpopulations of healthy people is scarcely known. In research studies of inflammation involving the UEGI tract, there is a lack of adequate healthy controls. Aims: To evaluate the histology of the UEGI tract and the duodenal lymphocyte subpopulations of healthy volunteers and patients with gastroesophageal reflux disease (GERD), the latter to assess if it could replace healthy subjects. Healthy individuals were excluded if they had symptoms, comorbidities, pregnancy, toxics, medications or abnormal blood analysis. Subjects in both groups with abnormal duodenal intraepithelial lymphocyte (IEL) counts were also excluded. A total of 280 subjects were assessed, and 37 were included (23 healthy and 14 with GERD). The GERD group showed a higher IEL count (median [IQR]: 19.5 [17–22]), than healthy group: (15 [12–18]), p = 0.004. Eosinophils, mast cells and intestinal morphometry were similar in both groups. In the lamina propria, CD4+ T cells decreased (p = 0.008), and CD8+ T cells increased (p = 0.014). The total innate lymphoid cells (ILC) and CD3− cells decreased (p = 0.007) in GERD group compared to healthy controls. At the intraepithelial level, NKT cells increased (p = 0.036) and ILC3 decreased (p = 0.049) in the GERD group. This is the first study to comprehensively map the histology, morphometry and duodenal subpopulations of healthy volunteers to help define a “gold standard” of normality. The differences found between both groups suggest that, whenever possible, healthy subjects should be included in research studies. Alternatively, we can consider a well-defined homogenous group with GERD to serve as the control group.

Background: Stenosis is one of the most common complications in patients with Crohn’s disease (CD). Endoscopic balloon dilation (EBD) is the treatment of choice for a short stenosis adjacent to the anastomosis from previous surgery. Self-expandable metal stents (SEMS) may be a suitable treatment option for longer stenoses. To date, however, there is no scientific evidence as to whether endoscopic (EBD/SEMS) or surgical treatment is the best approach for de novo or primary stenoses that are less than 10 cm in length. Methods/design: Exploratory study as “proof-of-concept”, multicentre, open-label, randomized trial of the treatment of de novo stenosis in the CD; endoscopic treatment (EBD/SEMS) vs surgical resection (SR). The type of endoscopic treatment will initially be with EDB; if a therapeutic failure occurs, then a SEMS will be placed. We estimate 2 years of recruitment and 1 year of follow-up for the assessment of quality of life, costs, complications, and clinical recurrence. After the end of the study, patients will be followed up for 3 years to re-evaluate the variables over the long term. Forty patients with de novo stenosis in CD will be recruited from 15 hospitals in Spain and will be randomly assigned to the endoscopic or surgical treatment groups. The primary aim will be the evaluation of the patient quality of life at 1 year follow-up (% of patients with an increase of 30 points in the 32-item Inflammatory Bowel Disease Questionnaire (IBDQ-32). The secondary aim will be evaluation of the clinical recurrence rate, complications, and costs of both treatments at 1-year follow-up. Discussion: The ENDOCIR trial has been designed to determine whether an endoscopic or surgical approach is therapeutically superior in the treatment of de novo stenosis in CD. Trial registration: ClinicalTrials.gov NCT 04330846. Registered on 1 April 1 2020. https://clinicaltrials.gov/ct2/home

Aims to obtain updated information on spanish female endoscopists: type of endoscopy performed, interest in endoscopy, difficulties in accessing or developing advanced endoscopy, and visibility of female endoscopists Methods we conducted a survey aimed at female gastroenterologists performing endoscopy in Spain, which was distributed through several scientific societies and social media. Results 504 responses were obtained, of which 486 were analyzed. Of the respondents, 320 (65.8%) performed basic endoscopy compared to 166 (34.2%) who performed advanced endoscopy. The factors associated with advanced endoscopy were the position held, the implementation of specific training, age and family burden. Among basic endoscopists, 237 (74.1%) would like to perform more complex procedures, and attributed their absence of dedication to advanced endoscopy to impossibility of dedication(65%), lack of possibility of training(47%) and lack of motivation at work (43%), in contrast to family reasons(10%) or radiological exposure(4%) that were minority causes. Among advanced endoscopists, 117 (70.5%) had found difficulties in their training. Main reasons were lack of training (62%), lack of motivation at work (48%) and in thirdly place pregnancy/child care (46%). Conclusions Endoscopy arouses great interest among female gastroenterologists, most of whom wish to perform advanced endoscopy. Classic reasons for the lack of dedication to advanced endoscopy among women have been replaced by others that need to be known in order to advance inclusiveness of women in endoscopy. Article published online: 14 April 2023 © 2023. European Society of Gastrointestinal Endoscopy. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany